Back to normal after surgery: dealing with a challenging case of traumatic cataract

Issue: March 1, 2000

ByMichela Cimberle

MILAN, Italy — A fine example of skillful surgery in a complicated case of traumatic cataract was presented on video at the Videocataract Congress here by Charlotta Zetterstrom, MD, PhD, of St. Erik’s Eye Hospital, Stockholm, Sweden.

The patient, a 40-year-old man, presented a severely traumatized eye, with cataract, mydriatic pupil, iris dialysis and more than one-half of the zonule missing (Figure 1).

Technique

“The patient was operated under general anesthesia. I was particularly concerned to perform a smooth and round capsulorrhexis to avoid tears. I then fixed four iris hooks around the capsulorrhexis edge to keep the lens well in place during surgery [Figure 2],” Dr. Zetterstrom said.

Hydrodissection was performed to loosen the nucleus and cortex within the capsular bag.

“As the patient was fairly young, the nucleus was not hard, and I could perform regular phacoemulsification with low settings and using a mixture of divide-and-conquer and a chopping technique to split the nucleus. I used the second instrument to divide the second half of the nucleus and also to keep the capsule away from the phaco tip [Figures 3, 4],” Dr. Zetterstrom said.

When the chamber became too shallow and phacoemulsification could not be continued without some risk, Dr. Zetterstrom injected Healon GV (sodium hyaluronate, Pharmacia & Upjohn) into the capsular bag to open it more fully. A capsular ring was then inserted. Once the ring was in place, aspiration could be completed, the bag was cleaned thoroughly from the remaining cortex and a foldable lens (AcrySof; Alcon, Fort Worth, Texas) was implanted (Figure 5).

“Of course, the lens could only be fixed in the bag and not in the sulcus, as it would have dropped into the vitreous,” Dr. Zetterstrom said.

The ring was then sutured to the sclera using two long, straight needles and Prolene thread.

Once the lens was centered, the iris retractors were removed.

“At this point, the mydriatic pupil had to be closed. I did a pupilloplasty, pulling the iris tissue with forceps and stitching it with Prolene sutures [Figures 6, 7, 8],” Dr. Zetterstrom said.

The iris dialysis was then sutured to the sclera using the same technique (Figure 9). At the end of the operation (Figure 10), and even more so the day after surgery (Figure 11), the iris and pupil had almost regained their normal shape. Natural healing processes will do the rest.

The patient presented a severely traumatized eye, with cataract, mydriatic pupil, iris dialysis and more than one-half of the zonule missing. (Figure 1)

Four iris hooks were fixed around the capsulorrhexis edge to keep the lens well in place during surgery. (Figure 2)

A second instrument was used to divide the second half of the nucleus and also to keep the capsule away from the phaco tip. (Figure 3)

A second instrument was used to divide the second half of the nucleus and also to keep the capsule away from the phaco tip. (Figure 4)

Once the ring was in place, aspiration could be completed, the bag was cleaned thoroughly from the remaining cortex and a foldable AcrySof lens was implanted and the ring was sutured to sclera. (Figure 5)

A pupilloplasty was performed, pulling the iris tissue with forceps and stitching it with Prolene sutures. (Figure 6)

A pupilloplasty was performed, pulling the iris tissue with forceps and stitching it with Prolene sutures. (Figure 7)

A pupilloplasty was performed, pulling the iris tissue with forceps and stitching it with Prolene sutures. (Figure 8)

The iris dialysis was then sutured to the sclera using the same technique. (Figure 9)

At the end of the operation (Figure 10), and even more so the day after surgery (Figure 11), the iris and pupil had almost regained their normal shape.

For Your Information:

Charlotta Zetterstrom, MD, PhD, can be reached at St. Erik’s Eye Hospital, SE-112 82, Stockholm, Sweden; (46) 8-672-3021; fax: (46) 8-651-0785; e-mail: Charlotta.Zetterstrom@ophste.hs.sll.se. Dr. Zetterstrom has no direct financial interest in any of the products mentioned in this article, nor is she a paid consultant for any companies mentioned.

Alcon can be reached at 6201 South Freeway, Fort Worth, TX 76134; (800) 862-5266; fax: (817) 241-0677.